OSCE Book - Child dental health including orthodontics Flashcards
You are a dentist in GP. A fit and healthy 10 year old girl has attended your practice with her parents for a second opinion. They have attended another dental practice where the dentist suggested that a decayed lower first permenant molar needed to be removed and also suggested that all the other healthy first permenant molars be removed as well. The family think this is unecessary and wish to have a second opinion.
History and examination reveal that she has an unrestorable grossly carious lower left first permenant molar tooth, which is pain free at the present time. There is no evidence of caries in any of the other teeth and all teeth appear to be developing nornally as seen on the OPT. She has a class 1 malocclusion with crowding in the buccal segments
Please explain to the family why the treatment plan was suggested.
Introduce yourself to the patient
Point to cover
- The 36 is unrestorable so needs to be removed. However this is a first permenant molar tooth and prior to xla we need to consider compensation or balancing the occlusion.
- In general the things to take into account on whether balancing/compensating extractions are needed are;
i) Whether there are missing teeth in the developing dentition (especially second premolars and third molars)
ii) The overall condition and long term prognosis of the other teeth and the other first molars
iii) The occlusion/malocclusion of the child
- Other factors to consider are the childs ability to cooperate with necessary dental treatment such as ortho and family access to dental treatment.
- In this case the child has a carious 36 and a class 1 occlusion with crowding in teh buccal segments. Guidelines from the royal college of surgeons (england) advise consideration of balancing extraction of the contralateral 6. To releave some crowding and stop midline shift. Compensating extractions of the upper 6’s are to be considered to prevent over-eruption and could help with pre-molar crowding. However there is little evidence to support centre line discrepancy with unilateral removal of first molars.
- Hence in ortho there is a tendancy to be more conservative with compensation and balancing extractions for first molars
- As teeth in this case are developing as normal. The child is at the best age to allow the teeth to erupt into appropriate position and limit the need for ortho tx later.
- An ortho opinion should be sought prior to finalising the treatment plan
- Hence it is understandable why the other GDP thought to extract other molars as if it is appropriately palnned and timed it can prevent further treatment in the future.
- Ask the family if they have any questions
10mins
A F&H 14 year old attends your practice for a routine check up. A clinical photograph of there mouth is show.
Please take a history from the patient to determine their concerns and likely causes of the condition. Explain to them what you think is/are the likely cause(s) for these clinical features, and the possible treatment options.
Introduce yourself to the patient. Ask the patient if they have any dental or facial concerns.
Ask if they have any problems with their ‘bite (occlusion).
Do they have any difficulty with eating.
Are they aware of the gap (anterior open bite, AOB)
between their top and bottom teeth? If yes, then when did they first notice it and has it changed with time?
Ask if they have ever sucked a thumb or finger, if so do they still do it, how often and for what duration in hours?
Explain to the patient the possible aetiology of AOB and what the likely aetiology is in their case.
Aetiology of AOB includes:
Habit (digit sucking): associated with asymmetrical AOB + posterior crossbite
Soft tissue (action of tongue): endogenous tongue thrust often symmetrical AOB
Skeletal pattern: associated with increased lower face high and Frankfort-mandibular plane angle
Localised failure of alveolar development: eg cleft lip and palate/ can be spontaneous.
In this case habit/digit sucking is the likely aetiology due to the following features: asymmetrical AOB with unilateral crossbite and non-coincident centre line.
Explain that the cessation of their habit can lead to spontaneous resolution of the AOB during the mixed dentition phase, but as this patient is older it is likely to improve the AOB but may not resolve. If the patient was in the mixed dentition stage then spontaneous resolution is more likely.
Assess if the patient wishes help to stop their habit.
Discuss ways to help with the cessation of their habit, eg thumb guard: an appliance to discourage their habit, this must be a removable appliance which may incorporate a midline screw to treat the crossbite. Other methods of reducing the pleasure of digit sucking. eg bad tasting nail polish.
10 Explain that if the AOB does not resolve then they could be referred for orthodontic assessment.
11 Ask if they have any questions.
Note features of AOB due to digit sucking:
Asymmetrical AOB
Unilateral cross bite + mandibular displacement (the sucking leads to narrowing of upper arch, cusp-cusp interference and possible displacement and centre line discrepancy)
Upper labial segment is proclined or spaced
Non-coincident central line
Partial eruption of teeth.
If the AOB is of skeletal cause then the patient would need to be referred for a joint orthodontic and surgical opinion as correction of the AOB may require orthodontic treatment in conjunction with orthognathic surgery.
AOB of soft tissue aetiology/tongue thrust cannot be treated due to relapse once the appliance is removed.
If the AOB is of skeletal cause then the patient would need to be referr
You are a dentist in general practice. A mother has broughther 6 year old daughter to your surgery for a routine check up. The child has had previous restorative work on her deciduous molar teeth.
Please give deitary advice to the mother and child.
Props
- Completed 3 day diet diary sheet.
The reason for giving dietary advice is to try to minimise dental disease caused by food and drink (eg decay and erosion)
Patients may be unaware of the cariogenic foodstuffs in their diet. Diet advice needs to be appropriate for the individual, as everyone is slightly different.
Introduce yourself politely to the patient and mother.
Establish rapport with the patient and mother.
You would start with a diet analysis. This should be for 3-4 days and include at least one weekend day.
Explain to the mother that she needs to record the time, the content and the amount of food and drink consumed as well as the toothbrushing times.
The examiner tells you the patient/mother has a completed diet sheet.
The diet sheet should be checked with the patient and mother and used as a aid when explaining diet advice to the mother and daughter
Assess nutritional value of main meals.
Highlight all sugar intake.
Highlight any between-meal snacks and assess nutritional value.
Keep advice short and simple, as overloading the patient and mother will be counter-productive.
Explain relationship between sugary snacks and drinks between meals and decay.
Possible hints to give:
Save sweets to a special time of the week, eg Saturday morning.
Eat sweets all in one go rather than spreading them out (ie a chocolate bar is less harmful than a bag of chocolates)
- Crisps nuts etc although more dentally friendly are high in salt and fat and should not be a subsitute for sweets
- Chewing gum and cheese will stimulate saliva flow and may help after eating sugary snacks although chewing gum may not be appropriate for young children
- Fizzy drinks contain large amounts of sugar. SUbsitute for milk and water wherever possibl e
- Diet drinks have low pH and can still damage teeth by eroding them
- Do not eat or drink after drushing your teeth at night. Brushing your teeth should be the last thing before bed
- Fruits do contain natural sugars however consuming normal amounts doesnt increase caries risk
Overall aim of diet advice
- Decrease the sugary snacks and fizzy drinks between meals
- Increase the amount of fruit and veg eaten
You are a dentist in GDP. A mother has brought her 2 year old son to see you for their first dental appointment. THe mother is unsure whether she should give her son fluoride supplements, as they live in a non-fluoridated area.
Please give fluoride advice to this mother and her son and explain your reasons for the advice given.
Introduce yourself to the patient
Establish rapport with the patient and parent.
Explain to the examiner that you would carry out a caries risk assessment for the child. This would involve assessing:
- Clinical evidence
- Diet history
- Medical history
- Fluoride
- Plaque control
- Social history
- Saliva
For a low-risk child, the child would only need a smear of toothpaste containing no less that 1000 pm fluoride. As soon as teeth erupt in mouth, brush twice daily.
For a high-risk child, use a smear or pea-sized amount of toothpaste containing 1350-1500 ppm fluoride. Topical fluoride application in the form of Duraphat® (2.26%)
3-4 times yearly would also be recommended.
Explain that fluoride has been shown to reduce caries experience (tooth decay) by 50%.
- Explain that fluoride is safe and there a multiple studys on there positive impact on teeth.
Fluoride can work on those teeth already erupted in the mouth, but will also have a beneficial effect on developing teeth (ie beneficial for the adult teeth).
There is an optimum level of fluoride ingestion. Exceeding this level can lead to problems of fluorosis, ranging from white opacities on the teeth to more severe discolouration and actual pitting of the teeth. Higher levels of fluoride ingestion can lead to toxicity and even death, so people must not exceed the advised dose. It is therefore important to know the level of fluoride in the drinking water supply before any fluoride supplements are prescribed.
- Children must then spit toothpaste after brushing adn not swallow. As well as not rinsing as will wash all teh good fluoride off the teeth
10mins
Please trace this cephalometric radiograph, and indicate the various cephalometric points used.
- S
- N
- A
- B
- Or
- Po
- ANS
- PNS
- Go
- Me
- Pg
- Gn
- Po-Or
- PNS-ANS
- Go-Me
S(sella) - mid-point of the sella turica
N(Nasion) - Most anterior point of the fronto-nasal suture.
A - Position of the max concavity on the anterior of the maxilla
B - Position of the maximum concavity on the anterior aspect of the mandible
Or (orbitale) - Most inferior anterior point on orbital rim
Po (porion) - Uppermost outermost point on bony external auditory meatus
ANS - anteiror nasal spine
PNS - Posterior nasal spine
Go (Gonion) - Most inferior point on the angle of the mandible
Me(menton) - Lowermost point on the mandibular symphysis
Pg (Pogonion) Most anterior point on the mandibular symphysis
Gn (Gnathion) - Most anterior and inferior point on the mandibular symphysis
Po - Or - Frankfort plane
PNS - ANS - maxillary plane
Go - Me - mandibular plane
What are the normal values for these cephalometric measurements in caucasains?
A fit and healthy 15 year old girl with a class 1 skeletal pattern and class 1 occlusion has attended you dental practice. She has retained upper right primary canine. Radiographs have revealed that the permenant successor is present and impacted. The radiographs are shown below.
The patient and her mother wish to know what options are available to treat the problem.
- Introduce yourself to the patient and mother
- Explain ot the patient and mother that the 13 is present and unerupted. Use the radiographs to aid this in your discussion. You can tell that 13 is palatally placed by parallax technique.
Explain treatment options
1. Leave alone but prepare for possible early loss of 53. Replace space in future with denture, bridge or implant. Also as leaving 13 will have to monitor for any cystic changes and resorption of adjacent teeth.
2. Surgically remove the permanent canine and leave the primary tooth in situ. There is possibility of damage to adjacent teeth during operation. Plus all common risks of surgical procedures.
3. Transplant the impacted 13 tooth inot the socket of the retained 53. This is only possible if there is adequate space to fit 13. The transplant can fail and ankylosis and resorption of the root can occur.
4. Orthodontontically resposition the tooth. Due to the favourable position and inclination of the impacted canine, the aim is to create space and bring the caine down into position either by interceptive treatment with creation of space to allow the canine to erupt into position or orthodontically resposition the tooth. This can be done by exposing and bonding the tooth followed by the use of an orthodontic appliance to bring into the arch.
5. Ask the patient if they have any questions
If the 13 canine had been in an unfavourable position then the options would be;
a) Leave alone, space closer or fill space. Then monitor for cystic changes and resorption
b) Transplant.
Fabourable or unfavourable position of the canine is related to
- The inclination of the 13
- The position of the canine
- Can it erupt into position
This 9 year old school boy has delayed eruption of his left central incisor.
A - What are the causes of unerupted central incisors?
- Ectopic position
- Crowding no space
- Supernumerary blocking it
- Dilacerated roots
- Pathology (cyst or odontome)
- Congenitally absent
- Retained primary teeth
- Early loss of primary teeth can cause delayed eruption
This 9 year old school boy has delayed eruption of his left central incisor.
B - Radiographs show that there is a midline supernumerary tooth present. How else may supernumerary teeth present?
A midline supernumerary tooth could present by causing
1. Displacement of permanent teeth
2. Crowding of permenant teeth
3. midline discrepancies
4. Midline diastema
5. Root resorption of adjacent teeth
6. Rotation of teeth
7. Occassionally the supernumerary does not cause any distruption ie no signs or symptoms only picked up by chance on radiograph
This 9 year old school boy has delayed eruption of his left central incisor.
C - Please explain to the parent accompanying the child how you would treat this?
- Introduce yourself to the patient Explain treatment options
- No treatment, this is not suitable as it has already delayed the eruption of central
- Await eruption of the supernumerary and then extracted it - this is not really suitable as the child is now aged 9 and the central incisor has not erupted, and it is unlikely that the supernumerary will erupt on its own accord
- Surgical removal of the supernumerary and allow the central incisor to erupt. There may not be adequate space for the incisor, in which case ortho treatment may be required to create space to accomodate incisor. Removal will probably need to be done under GA as it is still UE and the child is aged 9. It is necessary to ensure that the space is maintained in this region to allow the permanent tooth to erupt (URA). Traction may be necessary if incisor fails to erupt.
- Surgical removal of the supernumerary and bonding of the incisor with a bracket and gold chain to pull it into place. This would probs need to be done under GA
Ask if they have any questions
A mother brings along her fit and healthy 3 year old daughter who has fallen and avulsed her 61. They have brought the avulsed tooth in a cup of milk.
A - Explain your management of this. What possible complications do you need to warn the mother about?
- Introduce yourself to the patient
- Establish the nature of accident - how, whe and where it occured .
- Check that there are no other injuries other than to the tooth. Especially ask about loss of consciousness, nausea, vomitting or dizziness as these may imply head injury.
- Establish that truamatic injury best fits the description and there is no abuse or non accidental injury history.
- Establish past MH and DH
- Check the patient is up to date on vaccinations in particular tetanus
- As it is a primary tooth, the tooth must not be reimplanted to due risk of damage to permenant tooth.
- Warn the patient of possible sequelea
a) adjacent primary teeth;
- Discolouration. Id the teeth become grey early then the pulp may be vital and the discolouration reversible. But later on in indicative of pulp necrosis. Yellow discolouration suggests calcification and requires no treatment.
- Pulp death will require extraction.
b) To permanent teeth (depends on the stage of development, type and severity of injury, treatment and pulpal status)
- Hypomineralisation, hypoplasia, dilaceration, malformations, arrest of development.
Ask if patients mother has any questions or concerns?
A mother brings along her fit and healthy 3 year old daughter who has fallen and avulsed her 61. They have brought the avulsed tooth in a cup of milk.
B - How would this differ if the child was 10 years old and the tooth avulsed was the 21.
As the child is 10 years old that would be a permanent central incisor and should be re-implanted.
1. Check the tooth is intact and not fractured.
2. Check the soft tissues like lip for any possible tooth fragments.
3. Avoid handling the root of the tooth, remove any contaminant by gently agitating in saline
4. Re-implant under LA
Advice for Avulsions
* Hold by crown under cold running water for 10 secs
* Replace in socket- get child to bite onto tissue (don’t replant primary)
* If not replaced into the socket- store in milk, saliva or normal physiological saline
* can also place tooth between the cheek and gum
* Seek immediate dental advice
Avulsion- <60mins EAT and open apex
* Replant and splint 2 weeks
Avulsion- <60mins EAT and Closed apex
* Splint 2 weeks
* Pulp extirpation at 0-10 days
* Place AB steroid paste for 2 weeks (odontopaste or ledermix)
* Place NS CaOH
* Obturate 6-8 weeks later
Avulsion- >60mins EAT
* Scrub root clean of dead PDL cells
* Replant under LA
* Splint 4 weeks
* Extirpate at 7-10days
* NS CaOH for 4 weeks
* Obturate
These patients must be reviewed with trauma stamp regularly to look for signs of healing or necrosis.
Outcomes in Avulsions
- Pulpal- regeneration (open apices), uncontrolled infection, necrosis
- Perio- regeneration, PDL/cemental healing, Ankylosis, infection
- Root resorption
- Discolouration
- Mobility
Prognosis of traumatised tooth depends on?
- Stage of root development
- Type of injury
- If PDL is damaged
- Infection
- Time between injury and treatment
Management of fracture fragments of tooth in children?
- Swallowed- A&E
- Inhaled- A&E for chest x-ray
- ST- remove and suture
- Into environment- restore without
An 18 year old patient presents at your surgery with the above dentition.
A -Describe the clinical appearance in this photograph. Looking at centreline, OJ, OB etc
The patient is missing upper lateral incisors and a non-coincident centre line. They have reduced overbite and reduced over jet and features of class III buccal segments
An 18 year old patient presents at your surgery with the above dentition.
B - What are possible causes
Causes of missing incisors
1. Developmentally absent (hypodontia)
2. Previously extracted
3. Avulsed (unlikely bilateral)
4. Dilacerated/ displaced due to trauma (unlikely bilateral)
5. Supernumerary teeth preventing eruption
6. Crowding - insufficient space
7. Presence of pathological lesion
An 18 year old patient presents at your surgery with the above dentition.
C - How would you manage this patient?
- Introduce yourself to the patient
- From the history determine whether the teeth were ever present or have been removed
- Ask about possible trauma
- Check if family history of missing teeth
- Check MH
- Do a thorough I/O and E/O exam. Looking at cente line, displacement on opening, crossbite and possible U/E teeth
- Assess for periodontal health and look for evidence of caries
- SI take OPT
- A diagnosis can now be made
- missing upper lateral incisors
- Centre line discrepancy with or without displacement
- Class III malocclusion - Discuss treatment options with patient answering any questions
- Take informed consent
- Treatment - The various options for treatment depend on the cause and it is important to determine what the patients wishes are. The treatment options are;
- Leave the problem alone and do nothing
- Unerupted tooth. Leave as is, ortho repositioning - simple exposure or exposure and bonding, transplantation
- Dilacerated tooth. extract and treat as missing tooth.
- Missing tooth/replacement of missing teeth. RPD, adhesive bridge, implant.
- Orthodontics to align the canines (space closure) and camoflage unlikely to be successful as no crowding.
- Centreline discrepancy. If the patient is happy with upper centre line then accept. Otherwise fixed appliance will be required.
- Class III malocclusion. Check if patient is still growing. Possible referral to orthognathic clinic for surgery combined with ortho
IOTN must be used now to assess the need and eligibility of children under 18 years of age for NHS ortho treatment on dental health grounds.
Grade 1-2; Little to no treatment needed
Grade 3; Possible need of treatment
Grade 4-5; Definite need of treatment
There is also an aesthetics component
